The proposed Patient Safety Project encompasses two initiatives: (1) a project to improve the quality and completeness of reporting under the mandatory New York Patient Occurrence Reporting and Tracking System (NYPORTS), and (2) efforts to reduce the occurrence of adverse events and medical errors in general, and the sponsorship of three demonstration projects involving networks of eight to twelve hospitals that study a common and preventable error and develop and test interventions to reduce that error. The Patient Safety Project will enable to the DOH to more effectively collect, analyze, and utilize data collected through NYPORTS to inform state level policy and initiatives at the level of individual hospitals or hospital networks to reduce preventable errors and,improve patient safety. The New York State Department of Health (NYSDOH) will carry out the proposed Patient Safety Project in collaboration with the University of Albany, School of Public Health, Department of Health Policy, Management and Behavior. The School of Public Health, a joint venture created by the State University of New York and the State Health Department, is the first collaborative venture of its kind in the country. A Project Selection Panel consisting of national experts in quality improvement and quality assurance will be appointed to identify three NYPORTS occurrence codes (and a 4th alternate code) that will be the foci of study in the individual demonstration projects by networks of hospitals. The Project Selection Panel will consist of seven individuals. The panel will identify occurrence codes for further study based on the potential for prevention of error and impact on patient safety. A Project Oversight Panel will be appointed by DOH for each of the three demonstration projects. The Oversight Panels will select the hospitals that will conduct the demonstration projects, each of which will focus on a single NYPORTS occurrence code. Each Oversight Panel will consist of five individuals with expertise in the clinical area of study. The Oversight Panels will meet at the outset of each demonstration project and then three times per year to review progress and advise on future activities.